NCM 109: MCN

Semifinals: Gestational Conditions | April 13, 2023

Quezon, Britney Kim E. | BSN 2-L
GESTATIONAL CONDITIONS Therapeutic Nursing Management  Late Miscarriage
1. Hyperemesis Gravidarum Goal: Hospitalization is required for severe symptoms of Hyperemesis - spontaneous miscarriage happens after 16 wks
2. Ectopic Pregnancy Gravidarum which intravenous hydration and correction of metabolic (16-24 wks AOG)
3. Gestational Trophoblastic Disease (Hmole) imbalances are needed. Cause of Spontaneous Miscarriage
4. Incompetent Cervix a. Implement Common N/V Nursing Interventions  Abnormal fetal development
5. Spontaneous Abortion - Recommend smaller, frequent meals; include salty food  Immunologic factor
6. Placenta Previa - Suggest crackers before arising
 Implantation abnormalities
7. Abruptio Placenta - Avoid spicy and fried foods
8. Premature Rupture of Membrane - Advise to remain upright for 30 min after eating  Insufficient levels of progesterone
9. Pregnancy Induced Hypertension - Discuss use of antacids with primary care provider  Systemic infection
HYPEREMESIS GRAVIDARUM b. Treatment and Goals for Hospitalized Client  Ingestion of a teratogenic drug
 Otherwise known as Pernicious vomiting - Conrtol vomiting ( anti-emetics i.e. Reglan)  Ingestion of alcohol
 A serious condition in which nausea and vomiting of - NPO Assessment of Spontaneous Miscarriage
pregnancy has become prolonged past week 12 AOG or is - Progress to small feedings every 2-3 hours, then a. Vaginal Spotting with Slight Cramping – the presenting symptom
so severe that dehydration, ketonuria, and significant weight advanced to a soft diet, then to a normal diet. Assessment factor of vaginal bleeding during pregnancy:
loss occur within the first 12 weeks of pregnancy - Quiet environment  confirmation of pregnancy
- Intake & Output  pregnancy length in weeks
 Cause: unknown
- Adequate nutrition-nasogastric tube feeding may be
Suggested Causative Factors
necessary
 duration of bleeding
 High levels of HCG in early pregnancy Therapeutic Management  intensity (amount of bleeding occurred)
 Metabolic or nutritional deficiencies a) Pharmacology  frequency
 Thyroid dysfunction - sedatives  associated symptoms
 Ambivalence toward the pregnancy and family-related stress - antiemetics  action
 Most common in primigravid clients - correction of fluid and electrolyte imbalances  blood type
Assessment - IV lactated ringers Types of Miscarriage
 Nausea most pronounced on arising; however can occur at b) Complications I. Threatened MIscarriage
other times during the day - dehydration s/s: vaginal spotting w/ slight cramping (scanty at first, bright red)
- electrolyte imbalance
 Persistent vomiting - severe weight loss
no cervical dilation
 Weight loss Actions/Implementation:
- metabolic alkalosis
 Signs of dehydration (decreased urinary output, rapid pulse  assess fetal viability (FHR, ultrasound)
BLEEDING DURING PREGNANCY
rate, low-grade fever, dry skin, sunken eyes, dry lips) 1. Spontaneous Abortion / Miscarriage  test blood for HCG level (a double result means placenta is
 Electrolyte imbalances (↓ Na, K, chloride; hypokalemic 2. Ectopic Pregnancy still intact)
alkalosis) 3. Gestational Trophoblastic Disease  avoidance of strenuous activity for 24-48 hours
 Ketonuria 4. Premature Cervical Dilation  complete bed rest may not be necessary
 Increased hematocrit levels 5. Placenta Previa  offer emotional support
Diagnostic Tests and Lab 6. Abruptio Placenta  woman can resume her activities once bleeding stops after
SPONTANEOUS ABORTION / MISCARRIAGE: (1st Trimester
 Hematocrit, hemoglobin 48 hours
Bleeding)
 Electrolytes  coitus is restricted for 2 wks after the bleeding episode
Abortion II. Imminent (Inevitable) Miscarriage
 Urine protein and acetone - a medical term for any interruption of a pregnancy before a
Nursing Diagnosis A threatened miscarriage becomes imminent if uterine contractions
fetus is viable and cervical dilation occur
 Imbalance nutrition, less than body requirements, related to - viable fetus: a fetus more than 20-24 wks of gestation or one s/s: vaginal spotting with cramping
prolonged vomiting that weighs at least 500g positive uterine contraction
 Risk for deficient fluid volume related to vomiting secondary Miscarriage
cervical dilation
to hyperemesis gravidarum - an interruption of pregnancy that occurs spontaneously loss of some tissues (products of conception)
 Early Miscarriage
Action/Implementation:
- interruption of pregnancy occurs spontaneously
before 16 wks  Advise woman to come to the hospital if uterine contractions
and cramping happen.
 NCM 109: MCN
Semifinals: Gestational Conditions | April 13, 2023
Quezon, Britney Kim E. | BSN 2-L
 Assess/Monitor spontaneous vaginal bleeding and cramping  Position woman flat and massage the uterine fundus.  CVP or Pulmonary artery catheterization
 Save expelled tissues/clots.  Prepare patient for D&C.  D&C
 Count perineal pads to evaluate blood loss  Administer BT as prescribed.  Oxygen and other ventilatory support
 Monitor vital signs  Prepare replacement of fibrogen or another clotting factor as  Pharmacology:
 Provide IV fluids required/prescribed. a. Antibiotic (Penicillin, Gentamicin, clindamycin)
 Prepare client for dilatation and evacuation as prescribed.  Teach patient the importance of taking methylergonovine b. Tetanus toxoid
III. Complete Miscarriage maleate, including the dosage. c. Dopamine & Digitalis
The uterine products of conception are expelled spontaneously  Offer/provide emotional support. iv. Isoimmunization
without any assistance ii. Infection - the woman is Rh negative against Rh positive fetal blood
s/s: - its possibility is minimal if pregnancy loss occurs over a short which may enter the maternal circulation
- vaginal spotting and cramping (bleeding slows within 2 hrs, time, bleeding is self-limiting, and instrumentation is less - the production of maternal antibodies against Rh positive
and stops within a few days after the passage of the uterine - increase possibility may happen for women who have lost a blood
products large amount of blood management:
- cervical dilation - infectious organism: Escherichia coli  after a miscarriage, all women with Rh negative blood should
- uterine contractions s/s: receive Rh (D antigen) immune globulin (RhIg) to prevent
- passage of complete uterine contents (fetus, membranes, 
fever (38ºC) building-up antibodies in the event the conceptus was Rh
positive
and placenta) 
abdominal pain or tenderness
IV. Incomplete Miscarriage nursing problem:

foul vaginal discharge
A part of the conceptus is expelled (usually the fetus), but the
implementation:
 powerlessness or anxiety r/t loss of pregnancy
membrane or placenta is retained in the uterus
 Teach women the danger signs of infection.  sadness/grief
 Complication: maternal hemorrhage
 Instruct woman to wipe her perineal area from front to back
 The physician usually will prescribe dilatation and curettage after voiding and after defecation.
ECTOPIC PREGNANCY: 1st Trimester Bleeding
to evacuate the placental remains, clots, and other tissues. Main problem: implantation occurs outside the uterine cavity
 Caution her not to use tampons to control vaginal discharge.
 Do not give false hopes, the woman has to know that her Common Site:
pregnancy is lost  Encourage more intake of fluids. a. Fallopian Tube (95%) – tubal rupture occurs before 12 wks
V. Missed Miscarriage  Provide IV if required/as prescribed  Ampulla (80%)
 otherwise called as early pregnancy failure iii. Septic Abortion  Isthmus (12%)
- an abortion that is complicated with infection  Interstitial or fimbrial (8%)
 the fetus dies in the uterus but is not expelled - infection occurs more frequently in women who have tried to
s/s: b. Cervical
self-abort or were aborted illegally using a non-sterile c. Abdominal
- absence of fetal heart sound
instrument d. Ovarian
- no increase in size AEB; no increase in fundal height
- may lead to infertility d/t uterine scarring or fibriotic scarring *2% of pregnancies are ectopic
- painless vaginal bleeding
of the fallopian tube *the 2nd most frequent cause of bleeding early in pregnancy
Action/Implementation:
s/s:
 Ultrasound has to be performed  fever
Predisposing Factors
 Prepare client for D & E  Adhesion of the fallopian tube caused by chronic salpingitis
 crampy abdominal pain or Pelvic Inflammatory Disease
 Prepare client for labor if pregnancy is over 14 weeks.  tender uterus
Misoprostl (Cytotec) and oxytocin for elective termination of  Congenital malformations such as webbing in the fallopian
complications: tube
pregnancy.
 toxic shock syndrome  Scars from tubal surgery
 Provide IV fluids
 septicemia  Utrerine tumor pressing on the proximal end of the tube
 Offer emotional support/counselling
Complications of Miscarriage  kidney failure  IUD
i. Hemorrhage  death Assessment Findings
- not serious and fatal with complete spontaneous miscarriage management: *no unusual symptom at the time of implantation
- major hemorrhage is possible for incomplete miscarriage  CBC, serum electrolytes, serum creatinine, blood type &  amenorrhea or abnormal menstrual period/spotting – most
with accompanying coagulation defect (DIC) cross match, cervical, vaginal, & urine cultures. common sign (slight, dark vaginal bleeding)
Implementation:  I & O q hourly.  nausea and vomiting
 Monitor VS to detect possible hypovolemic shock  IVF administration.
NCM 109: MCN
Semifinals: Gestational Conditions | April 13, 2023
Quezon, Britney Kim E. | BSN 2-L
 positive pregnancy test  Start IVF, D5LR for plasma administration, blood
 tubal rupture signs: sudden, acute low abdominal pain transfusion, or drug administration as ordered.
radiating to the shoulder – KEHR’S SIGN (referred shoulder  Monitor V/S, bleeding, I & O
pain) or neck pain  Provide physical & psychological support.
 bluish navel (CULLEN’S SIGN) d/t blood in the cul-de-sac - anticipate grief
 sharp localized pain when cervix is touched - anticipate possible guilt responses
 signs of shock/circulatory collapse - anticipate fear related to potential disturbance in
Laboratory Findings childbearing capacity in the future
 low hemoglobin count, low hematocrit level d/t bleeding
process or loss of blood
 low HCG indicating that pregnancy has ended
 elevated WBC d/t trauma
Diagnosis
1. Pelvic Ultrasonography
- no embryonic sac in the uterine cavity
2. Culdocentesis
- aspiration of non-clotting blood from the cul-de-sac of
Douglas (positive tubal rupture)
3. Laparoscopy
- not common; requires direct visualization
- therapy for a ruptured ectopic pregnancy which is to
ligate the bleeding vessels, and to remove or repair the
damaged fallopian tube
Treatment
1. Methotrexate
- indicated for unruptured ectopic (mass) smaller than
4cm
- to induce labor and preserve fallopian tube
2. Salphingectomy
- surgical removal of ruptured tube
3. Management of profound shock if ruptured: blood replacement
and IVF
4. Antibiotics
Complications
1. Hemorrhage
2. Infection
3. Rh Sensitization – RhoGAM prevents isoimmunizations; given to
Rh negative mother with Rh positive ectopic pregnancy
Common Nursing Dx:
 powerlessness r/t early loss of pregnancy secondary to
ectopic pregnancy
Nursing Implementation
 Obtain assessment data rapidly especially for anticipatory
shock
 Implement measures for shock as soon as possible.
 Position patient on Modified Trendelenburg (shock)
NCM 109: MCN
Semifinals: Gestational Conditions | April 13, 2023
Quezon, Britney Kim E. | BSN 2-L
GESTATIONAL TROPHOBLASTIC DISEASE (HYDATIDIFORM c. ultrasound PREMATURE CERVICAL DILATATION (INCOMPETENT CERVIX)
MOLE / HMOLE) d. flat plate of the abdomen done after 15 weeks – no fetal skeleton  Previously termed as incompetent cervix
 Abnormal proliferation and then degeneration of the Prognosis:  A cervix that dilates prematurely and therefore cannot hold a
trophoblastic villi  80% remission after D&C; may progress to cancer of the fetus until term
 A developmental anomaly of the placenta that changes chorion – CHORIOCARCINOMA  It occurs in about 1 % of women
chorionic villi into a mass of clear visicles. Treatment:
 This commonly occurs at approximately week 20 of pregnancy
 Presents as an edematous grapelike cluster that may be a. Evacuation by D & C or hysterectomy if no spontaneous
the cervical dilation is painless
nonmalignant or may develop in choriocarcinoma. evacuation
Incidence: b. Hysterectomy if above 45 years old and no future pregnancy
Manifestations
 1:1500 pregnancies is desired, or with increased chorionic gonadotropin after D
 Show, a pink-stained vaginal discharge (first symptom)
 common in the Orient and in people of low socioeconomic &C
status c. HCG titer monitoring for one year – NO PREGNANCY for 1  Increased pelvic pressure
Cause: year (use contraception) because signs of pregnancy can  Rupture of membranes and discharge of amniotic fluid
 unknown mask early signs of choriocarcinoma  (+) uterine contractions
Risk Factors: d. Medical replacement: blood, fluid, plasma Associated Factors
 increased maternal age (women older than 35 years) e. Chemotherapy for malignancy: METHOTREXATE is the  Increased maternal age
drug of choice
 low socioeconomic status: low protein intake  Congenital structural defects
f. Chest X-ray to detect early lung metastasis
 blood group A women who marry blood group O men  Trauma to the cervix occurring after repeated D & C
Complications
Two Types of Molar Growth Diagnosis
a. Choriocarcinoma: most dreaded complication
1. Complete Mole
b. Hemorrhage: most serious during the early treatment phase  Usually diagnosed only after the pregnancy is lost
 all trophoblastic villi swell and become cystic
c. Uterine perforation  Can be detected early before the symptoms occur by
 embryo forms, it dies early at 1-2 mm in size; no fetal blood d. Infection SONOGRAM
in the villi Nursing Implementation Treatment
 karyotype is normal 46 XY or 46 XX , chromosome  Advise bed rest Cervical Cerclage
component was contributed only by the father, or an “empty
 Monitor VS, blood loss, molar/tissue passage, I & O  A surgical procedure is performed by suturing the cervix
ovum” was fertilized and was duplicated
 Maintain fluid & electrolyte balance, plasma, blood volume using purse-string technique by the vaginal route under
2. Partial Mole
through replacements as ordered regional anesthesia
 some villi form normally
 Prepare for D & C, hysterotomy, or hysterectomy as  Usually performed at weeks 12-14 of pregnancy after
 has 69 chromosomes
indicated confirming by sonogram that the fetus of a 2nd pregnancy is
Assessment Findings
 Provide psychological support; anticipate – healthy
 Brownish or reddish, intermittent or profuse vaginal bleeding
by 16 weeks with clear-fluid filled vesicles
- Fear related to potential development of cancer  Its purpose of the suture is to strengthen the cervix and
- Disturbance in self-esteem for carrying an abnormal prevent if from dilating
 Rapid uterine enlargement inconsistent with the age of
gestation.
pregnancy  the sutures are removed at weeks 37-38 of pregnancy
 Prepare for discharge  80%-90% success rate
 Symptoms of PIH before 20 weeks (↑BP, edema, - Emphasize the need for follow-up HCG titer
proteinuria)  Mcdonald Procedure
determination for 1 year
 Excessive nausea and vomiting d/t elevated HCG (1-2 M - nylon sutures are placed horizontally and vertically
- Reinforce instructions on NO PREGNANCY FOR ONE
IU/L/24 hours) across the cervix and pulled tight to reduce the cervical
YEAR; give instructions related to contraceptions.
 Positive pregnancy test canal to few millimeters in diameter
 No fetal signs – heart tones, parts, movements  Shirodkar Procedure
 Abdominal pain - sterile tape is threaded in a cervix and sutured in place
Diagnosis to achieve a closed cervix
a. Passage of clear-fluid filled vesicles – first sign that aids
diagnosis
b. Triad Signs:
- big uterus
- vaginal bleeding: brownish and intermittent
- HCG greater than 1 million (normal: 400,000 iu/L/24 hrs
NCM 109: MCN
Semifinals: Gestational Conditions | April 13, 2023
Quezon, Britney Kim E. | BSN 2-L
CONDITIONS ASSOCIATED WITH 3RD TRIMESTER BLEEDING C. Double Set-up (One set for vaginal delivery and another for ABRUPTIO PLACENTA
 placenta previa classical CS): prepared for IE in suspected placenta previa in the  A complication of late pregnancy or labor characterized by
 abruptio placenta following conditions: premature partial or complete separation of a normally
 premature rupture of membrane/preterm labor  Term gestation implanted placenta.
PLACENTA PREVIA  Mother in labor and progressing well  Also termed Accidental Hemorrhage/Ablatio Placenta
- low implantation of the placenta  Mother and fetus are stable  Incidence: 2nd leading cause of bleeding in the 3rd trimester;
Four Degrees - If the woman is not in labor or in shock, and/or fetus occurs in 1:300 pregnancies
1. Low-lying Placenta is distressed, only one set-up is to be prepared, an Predisposing Factors
- the implantation is lower rather than in the upper portion of emergency classical cesarean section set up  Maternal Hypertension: PIH, renal disease
the uterus (low-lying) D. Delivery: If conditions for watchful watching are absent:  Sudden uterine decompression as in multiple pregnancy and
- Marginal Implantation: the placenta edge approaches the  Vaginal delivery if birth canal is bot obstructed polyhydramnios
cervical os  Cesarean section if placental placement prevents vaginal  Advance age
2. Partial Placenta Previa
birth. In previa, classical cs is indicated as the lower uterine  Multiparity
segment is occupied by the placenta. Future pregnancies
- implantation of the placenta occludes a portion of the  Short umbilical cord
will be terminated by another CS because the presence of a
cervical os classical CS scar is a contraindication to vaginal delivery; it  Trauma: fibrin defects
3. Total Placental Previa is the leading the cause of uterine rupture. Types of Abruptio Placenta:
- implantation of the placenta totally occludes the cervical os Complications a) Type I: Concealed, covert, or central type; the classic type
Associated Factors:
 Hemorrhage  Placenta separates at the center causing blood to
 Increased parity  Prematurity
accumulate behind the placenta
 Advanced maternal age  External bleeding not evident
 Obstruction of birth canal
 Past cesarean births Nursing Implementation  Signs of shock not proportional to the amount of external
 Past uterine curettage a. Maintain bedrest – left lateral recumbent with a head pillow bleeding
 Multiple pregnancy b. DO NOT PERFORM an IE or vaginal examination b) Type II: Marginal, overt, or external bleeding type
Incidence rate: 5:1000 pregnancies c. Careful assessment : VS, bleeding, onset/progress of labor, FHT  Placenta separates at the margins
Outcome: Increase in congenital fetal anomalies d. Prepare client for diagnostic ultrasonography  Bleeding is external, usually proportional to the amount of
Assessment Findings e. Institute shock measures as necessary. Initially, bleeding in internal bleeding
 Painless vaginal bleeding (fresh, bright red and sudden) in previa is rarely life-threatening but may become profuse with  May be complete or incomplete depending on the degree of
the third trimester approximately week 30/7th month internal examination detachment
 Uterine soft/flaccid or intermittent hardening if in labor f. Provide psychological and physical support Assessment Findings
g. Prepare for conservative management, double set-up, or a a. Painful vaginal bleeding in the 3rd trimester
 Intermittent pain if it happens in labor secondary to uterine
classical CS b. Rigid, boardlike, and painful abdomen
contractions
h. Observe for bleeding after delivery: The lower uterine segment, c. Enlarged uterus d/t concealed bleeding; signs of shock not
 Bleeding may be slight or profuse which may come after an the site of placental detachment, is not a contractile as the upper
activity, coitus or internal examination proportional to the degree of external bleeding (classic type)
fundal portion d. If in labor: tetanic contractions with the absence of
Diagnosis
 Ultrasonography gives 95% accurate result – detects site of alternating contraction and relaxation of the uterus
placental implantation Diagnosis
Treatment a. Clinical diagnosis – signs and symptoms
A. Watchful waiting: Expectant management, conservative if any b. Ultrasound – detects the retroplacental bleeding
- the mother is not in labor c. Clotting studies – reveal DIC, clotting defects
- fetus is premature, stable, and not in distress  The thromboplastin from retroplacental clot enters
- bleeding is not severe maternal circulation and consumes maternal free
B. Amniotomy fibrinogen resulting in:
- artificial rupture of the bag of waters 1. DIC (Disseminated Intravascular Coagulation):
- causes fetal head to descend causing mechanical pressure small fibrin clots in circulation
at placental site controlling bleeding 2. Hypofibrinogemia: decrease normal fibrinogen
results in the absence of normal blood coagulation
NCM 109: MCN
Semifinals: Gestational Conditions | April 13, 2023
Quezon, Britney Kim E. | BSN 2-L
Complications
a. Hemorrhagic shock
b. COUVELAIRE UTERUS: The bleeding behind the placenta
may cause some of the blood to enter the uterine
musculature causing the uterine muscles not to contract well
once the placenta is delivered.
c. DIC
d. CVA secondary to DIC
e. Hypofibrinogenemia
f. Renal failure
g. Infection
h. Prematurity, fetal distress/demise (IUFD)
Nursing Implementations
 Maintain bedrest, LLR
 Careful monitoring:
- Maternal VS
- FHT
- Labor onset/progress
- I & O, oliguria/anuria
- uterine pain
- bleeding (not proportional to degree of shock)
 Administer intravenous fluid, plasma, or blood as ordered
 Prepare foe diagnostic exams – explain results
 Provide psychological support by preparing the patient for all
examination, explaining what is happening, and inform/explain
results
 Prepare for emergency birth either per vagina or CS
 Observe for ASSOCIATED PROBLEMS AFTER DELIVERY
- Poorly contracting uterus (Couvelaire uterus) leading to
post-partal hemorrhage
- Disseminated Intravascular coagulation (DIC) leads to
hemorrhage and possibly CVA
 Hypofibrinogenemia leads to post-partal hemorrhage
 Prematurity, neonatal distress that will lead to neonatal morbidity
and mortality